case studY Winnipeg - NCCDHnccdh.ca/images/uploads/Winnipeg_EN.pdf · 6 Bridging the gap BetWeen...

case studYWinnipeg

Bridging the gap Between research and practice

Making the Case for health equity internally: Winnipeg’s experienCe

Contact InformationNational Collaborating Centre for Determinants of Health St. Francis Xavier UniversityAntigonish, NS B2G [email protected]: (902) 867-5406fax: (902) 867-6130www.nccdh.caTwitter: @NCCDH_CCNDS

The National Collaborating Centre for Determinants of Health is hosted by St. Francis Xavier University.

Please cite information contained in the document as follows:National Collaborating Centre for Determinants of Health. (2012). Bridging the Gap between Research and Practice: Making the Case for Health Equity Internally: Winnipeg’s Experience. Antigonish, NS: National Collaborating Centre for Determinants of Health, St. Francis Xavier University.

Production of this document has been made possible through a financial contribution from the Public Health Agency of Canada through funding for the National Collaborating Centre for Determinants of Health.

The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada. This document is available in its entirety in electronic format (PDF) on the National Collaborating Centre for Determinants of Health website at: www.nccdh.ca.

La version française est également disponible au : www.ccnds.ca sous le titre Combler l’écart entre la recherche et la pratique : Argumentation à l’interne pour l’équité en santé : l’expérience de Winnipeg.

Making the Case for health equity internally: Winnipeg’s experienCe 3

acknoWledgements

This paper was researched and authored by Diana Daghofer of Wellspring Strategies Inc.

The preparation of this report would not have been possible without staff at the Winnipeg

Regional Health Authority and their partners who were interviewed to inform the

development of the case study.

Winnipeg Regional Health Authority staff:

• Horst Backe, Population Health Initiatives Leader

• Dr. Sande Harlos, Medical Officer of Health

• Lynda Tjaden, Director of Public Health

Winnipeg Regional Health Authority partners:

• Marli Sakiyama, Winnipeg Poverty Reduction Council

• Dr. Benita Cohen, University of Winnipeg

• Joan Dawkins, Executive Director, Women’s Health Clinic

National Collaborating Centre for Determinants of Health staff, specifically,

Claire Betker and Sume Ndumbe-Eyoh, provided guidance throughout

all phases of the project, including review of the final case study.

Sarah Viehbeck from the Canadian Institutes of Health Research- Institute

of Population and Public Health also provided external peer review.

about the national collaborating centre for determinants of health

The National Collaborating Centre for Determinants of Health is one of six National

Collaborating Centres (NCCs) for Public Health in Canada. Established in 2005 and

funded by the Public Health Agency of Canada, the NCCs produce information to

help public health professionals improve their response to public health threats,

chronic disease and injury, infectious diseases, and health inequities.

The National Collaborating Centre for Determinants of Health focuses on the

social and economic factors that influence the health of Canadians. The Centre

translates and shares information and evidence with public health organizations and

practitioners to influence interrelated determinants and advance health equity.

4 Bridging the gap BetWeen researCh and praCtiCe: Case study

introduction

A 2008 report on urban health1 showed that people living with the lowest socioeconomic status in

Winnipeg were showing up in city hospitals at two or three – sometimes even five – times the rate

of its wealthiest residents. Winnipeg had among the highest differences in hospitalization rates

between low and high socio-economic status groups in Canada. The report provided relevant, local

and comparative health data – a catalyst for action on health disparity in that city. Public health

leaders used the opportunity to strengthen ties with anti-poverty and other community organizations,

and to raise the profile of health inequity with senior management within their health region. Will

their efforts translate to improvements in the health of Winnipeg’s poorest residents? This is an

ongoing story that describes an innovative way to cast a health equity lens over all aspects of the

Winnipeg Regional Health Authority, including health services delivery and long-term care.

about the case study

This case study is one of four case studies that illustrate the application of social determinants of health

(SDH) in public health. Each of the case studies reflects a different geographical region of Canada. The

case studies were developed as a knowledge exchange tool to support a workshop hosted by the National

Collaborating Centre for Determinants of Health and the Canadian Institutes of Health Research Institute

of Population and Public Health in Toronto, Ontario on February 14-15, 2012.

To enable learning and possible implementation of the processes discussed at the workshop, the four

case studies were developed. Each case study includes a description of the context, issues addressed,

activities undertaken and the possible application of the approach to public health work.

The process used to develop the case studies is outlined in Bridging the Gap between Research and

Practice: methodology for case study development.

Other case studies in the series include:

• Building Leadership Competency in Public Health: Taking advantage of changes

in health delivery in Québec

• Empower the Community: New Brunswick’s Approach to Overcoming Poverty

• Improving Health Equity in Saskatoon: From Data to Action

All documents are available at www.nccdh.ca

5Making the Case for health equity internally: Winnipeg’s experienCe

setting the stage: health disparity in Winnipeg

As described in the Canadian Population Health

Initiative report, Reducing Gaps in Health: A Focus

on Socio-Economic Status in Urban Canada2,

Winnipeg had among the highest differences in

hospitalization rates between low and high socio-

economic status groups in Canada, in 7 of the 13

indicators studied. The differences were greater

than in most other Canadian cities for:

• Asthma in children – 3.0 times

(pan-Canadian average – 1.6)

• Injuries in children – 2.5 times


• Injuries for all ages – 2.2 times


• Unintentional falls – 1.8 times


• Land transport accidents – 1.9 times


• Diabetes – 3.7 times


• Substance-related disorders – 5.0 times


The urban health report provided local, timely,

comparative health data that pointed to serious

health inequity in Winnipeg. Preparation for

anticipated media questions made the evidence

a key catalyst to raise the profile of health

disparity among senior management and

key leaders at the Winnipeg Regional Health

Authority. While the media attention was less

than predicted, the presentation of the data by

the Population and Public Health staff and the

Research and Evaluation team resonated with

senior management. It validated and increased

visibility of the issue that was already known

to staff in an informal, intuitive way, as well as

from other reports and studies over years.

For senior management, the data fit with their

experience of high demand for acute care

services seen in higher admission rates or

longer lengths of stay in Winnipeg hospitals

compared to other urban centres in Canada. It

countered the interpretation that differences in

acute care were solely due to inefficiencies, and

pointed to a population that is sicker and has

more social complexities than in other urban

centres and may, therefore, require more care.

The resulting regional response had two

main thrusts – one to strike a committee to

work internally to identify issues that could

be addressed to reduce health disparity

through ongoing programs, processes and

leadership, and another to work more closely

with partners in the community. Efforts began

to produce a report to stimulate conversation

with the community - with partners at all

levels – to create a regional strategy with

recommendations that all parties could act upon.

the issue/challenge

Responses to an internal questionnaire showed

that many groups within the Winnipeg Regional

Health Authority had a good understanding of

health equity and could articulate their equity

promotion activities and plans. At the same time,

others had little recognition that promoting health

equity required anything more proactive than

just “opening doors to all comers”. Also, there

was no common framework or regional strategy

Bridging the gap BetWeen researCh and praCtiCe: Case study6

to pull the work together. To make a difference

in health equity, it was critical to make the case

that equity promotion should be a recognizable

part of the organizational culture and become

top of mind for all planning and service delivery.

the environment

the cihi report stimulated two

regional commitments in 2009:

1. A committee was formed with broad

representation from senior managers and

staff of Winnipeg Regional Health Authority

programs and sites, spanning acute to

community care, to explore a regional

disparity reduction strategy (later reframed

as a health equity promotion strategy).

2. The Winnipeg Regional Health Authority

increased its participation in the newly

formed Winnipeg Poverty Reduction

Council to assist in addressing root causes

of health disparity and to nurture new

partnerships in the community. Within

Winnipeg, an increasing critical mass to

address poverty seemed to be forming.

key Players

The internal health disparity/health equity

promotion committee, the Promoting Health

Equity Oversight Committee, was named to

reflect a strengths-based approach. Its aim

was to identify issues that could be addressed

to reduce disparity through ongoing programs

and processes within the Winnipeg Regional

Health Authority, and to work more closely

with partners beyond health care to promote

health equity. At the same time, Winnipeg

Regional Health Authority began to work with the

Winnipeg Poverty Reduction Council - providing

resources and having staff on their committees

to ensure a health presence in their planning.

The Promoting Health Equity Oversight Committee

is chaired by the Medical Officer of Health,

Population and Public Health. It began in earnest

in September 2010 (delayed due to the H1N1

pandemic). It is a large internal group (over 30

people), with three executive co-sponsors at

the Vice-President/Executive Director level, and

representation from community care, acute

care and long term care, and key sites and

programs, including community health agencies.

The Oversight committee reports to senior

management through the Regional Management

Committee with updates at least every six months.

three working groups are currently active:

• Partnership Working Group (about 10

members) - to identify and maximize

external partnerships with organizations

addressing health and social issues

related to socioeconomic status

• Planning Working Group (about 10 members)

– to insert consideration for health equity into

all operational decision making (planning,

finance, logistics and human resources)

• Directional Working Group (about 15

members) – to research and describe

local health equity status and best

practice intervention recommendations,

and draft the Winnipeg Health Region

Health Equity Promotion directional

report, based on available evidence.


The Directional Working Group is developing

a report to stimulate further discussion,

consultation and engagement, to form the

basis for an action plan on specific priority

areas of intervention. Three task teams have

been established to help prepare the report:

Describing the Problem, Best Practices and

Communications. After completion of the report

and consultations, the Directional Working

Group and its task teams will likely disband and

be replaced by Action Plan working groups to

focus on implementing the recommendations.

the Process to implement action aimed at reducing health disparity

all Working groups and task teams

are actively gathering research to

inform their actions, including:

1. An environmental scan and gap analysis

of organizations most actively involved in

poverty-related health equity work in the

community and at the regional, provincial,

national and international levels. To date,

over 100 existing partners have been

identified. (Partnership Working Group).

2. Indicators to describe health inequity in

the health region, with candidates being

researched through a review of 14 local

reports to determine the immediate

availability of data (and associated gaps)

specific to these indicators. Reports reviewed

include community health assessments,

reports of the Manitoba Centre for Health

Policy (University of Manitoba), as well as

population and disease-specific reports

(Describing the Problem Task Team).

3. Key recommendations to promote health

equity, found by reviewing over 80 resource

documents or websites. Over 1000

recommendations have been gleaned through

this review. (Best Practices Task Team)

4. Program budgeting and marginal

analysis process where equity was

one of twelve criteria used to assess

new initiatives (influenced by the work

of the Planning Working Group).

Bridging the gap BetWeen researCh and praCtiCe: Case study8

overcoming challenges

Finding evidence and expertise – Although

there are no formal links to external research

organizations, academics and other researchers

are included on all committees or consulted

when required. While more formal agreements

would be helpful, good relationships exist

with individual researchers and institutions,

and fruitful collaborations exist.

Competing interests for budget – Funding

health disparity work would contribute greatly

to a sustainable health care system, but shifting

dollars to health equity efforts is challenging. It

will require the right evidence – and courage – to

move funds from health services to preventive

work. For example, improving the lives of

homeless people will result in fewer visits to the

emergency room, but decision-makers will need

to see more than evidence to make these changes.

Health system and public support will be required.

Establishing priorities – After reviewing a

wide range of health equity reports, over 1000

recommendations have been collected. Setting

‘doable’ priorities has yet to take place. To do so,

actions need to be identified that are both important

and feasible, based on evidence and examples

from other communities. Other considerations

will include partners’ and other stakeholders’

views of the relevance of various actions, and

their potential roles in working towards them.

Determining roles – While the Winnipeg

Regional Health Authority is stepping up its

role in health equity, staff recognize that many

organizations came before them in addressing

inequities. They consciously work to connect with

those already involved, to recognize them, and to

add value to their work with the intent to amplify,

not overtake, their efforts. They recognize the

need to earn, not demand, credibility.

Public health advocates – Advocacy must be

approached with considerable finesse, particularly

when coming from within a government funded

department, health authority or organization.

It is an important public health tool, but needs

to be applied strategically. Approaches that

stimulate effective action may not necessarily be

those that involve open and public challenges to

the government of the day – civic or provincial.

Advocacy efforts, mentoring and support

can occur at many levels, both within a large

health organization, and with partners.

“

”

public health, or even the health region, doesn’t need to own or manage everything that is going on. in many cases, we can be the ‘cheerleaders’, not the ‘flag-bearers’. at the same time, we need to coordinate our efforts, to make sure each partner is taking on the right role.Whra puBliC health staff


developing common ownership of health equitya key strategy to build momentum on any issue is to create a sense of common or shared ownership. the Winnipeg regional health authority is using multiple approaches, both formal and informal, to develop a sense of joint responsibility. it is hoped that if senior management, committee members and staff are exposed to equity issues in many different ways, the health equity lens will seep into their mindset. some of the approaches being used are:

• build on existing efforts – It is important to recognize the past and ongoing efforts of the many people who have worked on health equity for their entire careers. Regional staff avoid portraying theirs as a new initiative, but rather as one that is coming alongside and adding energy to longstanding, commendable work.

• nurture champions – Working with individuals both inside and outside the organization, staff are trying to establish champions for health equity. Internal leaders, particularly those who have a longstanding commitment to the issue, are being recruited to leadership positions on the Oversight Committee, working groups or task teams. Community opinion leaders, who are influential and bring extensive networks, are being invited to join groups, thereby increasing their investment and ownership. At all levels, staff promote the work to key individuals through meetings or conversations.

• create links between evidence and existing priorities – Connections between health equity and existing key

priorities of Winnipeg Regional Health Authority are being established. Just as data from the CIHI report was a catalyst for action, ongoing analysis of process and outcome indicators will allow managers to determine how actions on health equity are affecting other outcomes. The ‘business case’ for health equity must dovetail with other issues management is addressing.

• communicate – Learning a lesson from the lack of visibility early on in their efforts, staff are now using a variety of measures to keep health equity a priority, from written updates, to personal conversations, to putting the issue of health equity on the agenda for the Board of Directors’ annual retreat.

• be part of the community – the Winnipeg Regional Health Authority has recently re-located its corporate offices to the inner city, providing an opportunity for staff to be closely involved in the community that confronts considerable challenges related to health equity.

• Partner with a community school – In 2009, a partnership was created between

William Whyte School, located in the inner city, and the Winnipeg Regional Health Authority corporate office staff. In addition to providing funding, staff are helping with fundraising, inviting students to perform at the Winnipeg Regional Health Authority corporate events, and awarding “You Can Do It” cash prizes, which are held in trust for winners’ post secondary educations. Feedback has shown higher school attendance and return rates, attributed to volunteer efforts. The relationship continues, with consideration to expand to a second school.

• Put ‘skin in the game’ at the Winnipeg Poverty reduction council – Winnipeg Regional Health Authority provides resources, including initial funding for a position within the Winnipeg Poverty Reduction Council, to ‘keep an ear to the ground’ regarding initiatives related to health equity. This enhances networking, by creating an infrastructure in which existing groups are linked, from the grass-roots to the policy level.

10 Bridging the gap BetWeen researCh and praCtiCe: Case study

“”

having people step into leadership roles increases sense of being ‘inside’ the issue and part of the action. Whra puBliC health staff

maintaining leadership and motivationWhile public health is leading the process, ongoing leadership is required to maintain momentum

for a health equity initiative.

• embed equity within formal and informal leadership structures – A number of positions of influence exist throughout the health region, and it is critical that equity take hold within at least one of them, to change the tone, direction and priorities of the system. Otherwise, it is very difficult for public health to have an impact on organizational practices and culture.

• motivate through involvement - Keeping people motivated requires an understanding of their interests and the benefits they get from being involved. Feeling that they are part of something important, meaningful and successful is

key. It is particularly important to recognize what motivates champions and to facilitate the sense of satisfaction that drives them.

• balance the pace of work – It takes time to fully engage people, but once established, efforts must move quickly enough to see results – recognizable ‘wins’.

• keep equity ‘on the agenda’ – The work of health equity must be profiled from many directions, in many forums, so being involved creates a sense of belonging to something that is big and pervasive. Relating the work to existing priorities and events is important, so people see the relevancy of their work on an ongoing basis.

• communicate, encourage, and appreciate – It is easy for people to start to feel disconnected and drift away. Staff make a point of keeping in touch – with calls, email, visits, chats – with a sense of appreciation rather than demand, so people realize they are needed but not taken for granted.

• harness critical mass – Issues that get profile, build more profile. Issues that get people involved, attract more people. Involving senior leaders gets management involved, and once management is involved, senior management keeps

hearing about the issue.

strengths of the Winnipeg approach• A region-wide committee

leading efforts

• All sectors involved at the working level (working groups, task teams)

• Common ownership, including the endorsement and involvement of senior Winnipeg Regional Health Authority management

• Well-established and effective relationships in the community and with researchers


?

• Regional Health Plan proposals are being

evaluated with health equity as a criterion.

• Population and Public Health strategic

plans are being developed around the

concept of ‘targeted universality’.

• Consideration is being given to

further refining how public health

resources are allocated - on the basis

of community need, not population.

• Draft conceptual frameworks

have been proposed.

• Mapping discussions are underway.

• The Winnipeg Regional Health Authority

Health Equity report is currently being drafted.

how would you present the case for action on health equity to decision-makers in your organization? What arguments would you use to urge them to action?

how would you best engage community partners and researchers involved in the process, to help get management ‘buy-in’ and stimulate the translation of research into action?

how would you overcome the following challenges to implement a health equity strategy in your situation?

• develop a sense of common ownership • find the evidence, expertise and

resources required • maintain leadership and motivation • set doable priorities

having read about Winnipeg’s effort, what are the elements you think will lead to its success? how would you apply these elements to your own situation?

questions to Consider

references

1 Canadian Institute for Health Information. (2008). Reducing Gaps in Health: A Focus on Socio-Economic Status in Urban Canada. Ottawa, ON: Canadian Institute for Health Information.

2 Ibid.

While still early in its process, Winnipeg Regional Health Authority has been able to accomplish a considerable amount, including:

national collaborating centre for determinants of health

St. Francis Xavier University Antigonish, NS B2G 2W5tel: (902) 867-5406 fax: (902) 867-6130

email: [email protected] web: www.nccdh.ca

case studY Winnipeg - NCCDHnccdh.ca/images/uploads/Winnipeg_EN.pdf · 6 Bridging the gap BetWeen...

Documents

Transcript of case studY Winnipeg - NCCDHnccdh.ca/images/uploads/Winnipeg_EN.pdf · 6 Bridging the gap BetWeen...